1. (1) General Provisions. Each hospital shall have a planned, systematic, hospital wide approach to the assessment, and improvement of its performance to enhance and improve the quality of health care provided to the public.

   1. (a) Such a system shall be based on the mission and plans of the organization, the needs and expectations of the patients and staff, up-to-date sources of information, and the performance of the processes and their outcomes.

   2. (b) Each system for quality improvement, which shall include utilization review, must be defined in writing, approved by the governing board, and enforced, and shall include:

      1. A written delineation of responsibilities for key staff;

      2. A policy for all privileged staff, whereby staff members do not initially review their own cases for quality improvement program purposes;

      3. A confidentiality policy;

      4. Written, measurable criteria and norms;

      5. A description of the methods used for identifying problems;

      6. A description of the methods used for assessing problems, determining priorities for investigation, and resolving problems;

      7. A description of the methods for monitoring activities to assure that desired results are achieved and sustained; and,

      8. Documentation of the activities and results of the program.

2. (2) Each hospital shall have in place a systematic process to collect data on process outcomes, priority issues chosen for improvement, and the satisfaction of the patients. Processes measured shall include:

   1. (a) Appropriate surgical and other invasive procedures;
   2. (b) Preparation of the patient for the procedure;
   3. (c) Performance of the procedure and monitoring of the patient;
   4. (d) Provision of post-procedure care;
   5. (e) Use of medications including prescription, preparation and dispensing, administration, and monitoring of effects;
   6. (f) Results of autopsies;
   7. (g) Risk management activities;
   8. (h) Quality improvement activities including at least clinical laboratory services, diagnostic imaging services, dietetic services, nuclear medicine services, and radiation oncology services.

3. (3) Each hospital shall have a process to assess data collected to determine:

   1. (a) The level and performance of existing activities and procedures,
   2. (b) Priorities for improvement, and,
   3. (c) Actions to improve performance.
4. (4) Each hospital shall have a process to incorporate quality improvement activities in existing hospital processes and procedures.

Rulemaking Authority 395.1055 FS. Law Implemented 395.1055 FS. History–New 9-4-95, Formerly 59A-3.216.